Applied Evidence

When guideline treatment of asthma fails, consider a macrolide antibiotic

Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison
[email protected]

The author reported no potential conflict of interest relevant to this article.

This class of drugs has the potential to benefit patients with persistent, poorly controlled asthma and those with new-onset disease as an adjunct to first-line therapy.

PRACTICE RECOMMENDATIONS

› Consider a trial of ­azithromycin for patients who have poorly ­controlled persistent asthma and are not responding to ­guideline ­treatment with the ­combination of an inhaled corticosteroid and either a long-acting ­bronchodilator or long-acting ­muscarinic antagonist. B

› Consider a trial of azithromycin in ­addition to first-line guideline therapy for patients who have new-onset asthma. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series


 

References

In vitro laboratory and in vivo animal models support the biologic plausibility that chronic infection is a potential cause of asthma.1,2 Arising from that hypothesis, macrolide antibiotics have been the subject of clinical trials and other studies to determine whether these drugs are efficacious in the long-term management of asthma in adults and children. Macrolides might also have immunomodulatory and antiviral properties that can benefit patients with asthma.3

Lung filled with pills

In vitro laboratory and in vivo animal models support the biologic plausibility that chronic infection is a potential cause of asthma.

This article looks at the evidence and clinical scenarios for the use of macrolides in asthma, provides proposed dosing schedules, and reviews associated concerns, including adverse effects, risk of bacterial resistance, and cost.

3 cases to consider

CASE 1 Paul D developed severe, refractory asthma at 30 years of age after an acute respiratory illness. At age 40, he was treated with 14 weekly doses of azithromycin. His asthma resolved slowly over 12 months.

Outcome. Mr. D has remained free of symptoms of ­asthma for more than 20 years.

CASE 2 Casey K developed severe wheezing at 18 months of age after an acute respiratory illness. Refractory asthma symptoms persisted until 6 years of age, at which time he was given 12 weekly doses of azithromycin. Asthma symptoms gradually resolved.

Outcome. Casey was able to resume normal physical ­activities, including competitive swimming.

CASE 3 Amy S, who had no history of respiratory problems, presented at 30 years of age with a 3-month history of wheezing and dyspnea after an acute respiratory illness. She was treated symptomatically with bronchodilators; wheezing failed to resolve. After 6 months of persistent wheezing that significantly affected her exercise capacity, Ms. S was given a diagnosis of persistent asthma and received 12 weekly doses of azithromycin.

Continue to: Outcome...

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